Healthcare Provider Details

I. General information

NPI: 1326065897
Provider Name (Legal Business Name): FREDS STORES OF TENNESSEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PLANK ROAD HWY 128
ST. JOSEPH LA
71366
US

IV. Provider business mailing address

6625 LENOX PARK BLVD. SUITE 200
MEMPHIS TN
38115
US

V. Phone/Fax

Practice location:
  • Phone: 318-766-4563
  • Fax: 318-766-4522
Mailing address:
  • Phone: 901-238-2520
  • Fax: 901-365-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5000
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5000
License Number StateLA

VIII. Authorized Official

Name: RAHUL KUL KARNI
Title or Position: SVP OF FINANCE
Credential:
Phone: 800-374-7417